Validation of the Emergency Department-Paediatric Early Warning Score (ED-PEWS) for use in low- and middle-income countries: A multicentre observational study

Early recognition of children at risk of serious illness is essential in preventing morbidity and mortality, particularly in low- and middle-income countries (LMICs). This study aimed to validate the Emergency Department-Paediatric Early Warning Score (ED-PEWS) for use in acute care settings in LMICs. This observational study is based on previously collected clinical data from consecutive children attending four diverse settings in LMICs. Inclusion criteria and study periods (2010-2021) varied. We simulated the ED-PEWS, consisting of patient age, consciousness, work of breathing, respiratory rate, oxygen saturation, heart rate, and capillary refill time, based on the first available parameters. Discrimination was assessed by the area under the curve (AUC), sensitivity and specificity (previously defined cut-offs < 6 and ≥ 15). The outcome measure was for each setting a composite marker of high urgency. 41,917 visits from Gambia rural, 501 visits from Gambia urban, 2,608 visits from Suriname, and 1,682 visits from Tanzania were included. The proportion of high urgency was variable (range 4.6% to 24.9%). Performance ranged from AUC 0.80 (95%CI 0.70-0.89) in Gambia urban to 0.62 (95%CI 0.55-0.67) in Tanzania. The low-urgency cut-off showed a high sensitivity in all settings ranging from 0.83 (95%CI 0.81-0.84) to 1.00 (95%CI 0.97-1.00). The high-urgency cut-off showed a specificity ranging from 0.71 (95%CI 0.66-0.75) to 0.97 (95%CI 0.97-0.97). The ED-PEWS has a moderate to good performance for the recognition of high urgency children in these LMIC settings. The performance appears to have potential in improving the identification of high urgency children in LMICs.

Epidemiology and Mortality of Early-Onset Neonatal Sepsis in Suriname: A 2-Year Surveillance Study

We conducted a nationwide surveillance study to produce reliable national estimates on incidence, etiology, and mortality of early-onset neonatal sepsis (EONS) in Suriname. The estimated national population incidence rate of EONS was 1.37 (95% CI: 0.90-1.99) per 1000 live births and in-hospital mortality was 25.9%.

Viral causes of severe acute respiratory infection in hospitalized children and association with outcomes: A two-year prospective surveillance study in Suriname

BACKGROUND

Viruses are the most frequent cause of severe acute respiratory infection (SARI) in children. It is currently unknown whether presence of a virus, the number of viruses, or type of virus, are associated with clinical outcomes of pediatric SARI in developing countries.

METHODS

Between 2012 and 2014 nasopharyngeal swabs and demographic and clinical variables were prospectively collected for surveillance of viral causes of SARI in Surinamese children within 48 hours after hospitalization. These swabs were tested for 18 respiratory viruses using a multiplex polymerase chain reaction (PCR) panel to identify the specific viral causes of SARI, unknown to the treating physicians. In post hoc analyses we evaluated if the PCR results, and demographic and clinical characteristics, were associated with course of disease, duration of respiratory support, and length of stay (LOS).

RESULTS

Of a total of 316 analyzed children, 290 (92%) had one or more viruses. Rhinovirus/enterovirus (43%) and respiratory syncytial virus (34%) were most prevalent. Course of disease was mild in 234 (74%), moderate in 68 (22%), and severe in 14 (4%) children. Neither presence of a single virus, multiple viruses, or the type of virus, were different between groups. Prematurity and lower weight-for-age-z-score were independent predictors of a severe course of disease, longer duration of respiratory support, and longer LOS.

CONCLUSIONS

Viruses are common causes of pediatric SARI in Suriname, yet not necessarily associated with clinical outcomes. In developing countries, demographic and clinical variables can help to identify children at-risk for worse outcome, while PCR testing may be reserved to identify specific viruses, such as influenza, in specific patient groups or during outbreaks.

Infectious pseudo-aneurysm of the left ventricle: a case report and a review of the literature

BACKGROUND

In the workup of a pediatric patient with pericarditis we found evidence of a pseudo-aneurysm of the left ventricle, which is a rare complication of purulent pericarditis.

CASE PRESENTATION

We present a case of a six-year-old girl who was diagnosed with pericarditis and a fistula between the pericardial and the intra-luminal space of the left ventricle of the heart. She was successfully treated with antibiotics and cardio-thoracic surgery. We found 23 published cases (21 with follow-up) of infectious pseudo-aneurysm of the heart, of which 19 underwent surgery, 5 had fatal outcome, and 2 who refused surgery survived. The majority of cases were associated with Staphylococcus aureus. The exact mechanisms of this rare complication remain unknown.

CONCLUSIONS

A pseudo-aneurysm of the left ventricle is a rare and not well understood complication of a purulent pericarditis most commonly caused by Staphylococcus aureus infection. Because of risk of rupture, surgical intervention is advised.

[Dengue: a growing risk to travellers to tropical and sub-tropical regions]

Dengue is currently the most common arboviral infection worldwide. Due to global climate change and other factors, the vector of the virus - the Aedes mosquito - has spread considerably over the past decades. Dengue is endemic in almost all tropical and sub-tropical regions of the world; meaning that approximately 40% of the world population is at risk of acquiring a dengue infection. The clinical features of dengue vary from a non-specific febrile illness (dengue fever) to at times fatal serious conditions such as dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). Considering the limited possibilities of prevention it is anticipated that the incidence of dengue will increase in the future. It is expected that health-care providers in non-endemic regions will encounter dengue-infected patients with increasing frequency in their practices.

Severe persistent pulmonary hypertension of the newborn in a setting where limited resources exclude the use of inhaled nitric oxide: successful treatment with sildenafil

We present the case of a full term neonate with severe persistent pulmonary hypertension of the newborn (PPHN) after birth asphyxia cared for at the St. Elizabeth Hospital in Curacao, Netherlands Antilles. Although the child was ventilated with high pressures and was given high doses of cardiovascular pressors, the arterial oxygen levels remained low with an alveolar-arterial O2 gradient of 651 mmHg. As a last resort, sildenafil (1.5 mg/kg) was given via a nasogastric tube. This resulted in an immediate and sustained elevation of arterial oxygenation and subsequent complete recovery. After administration of sildenafil there was a transient hypotension which was corrected by a single bolus of saline.

CONCLUSION

We discuss the current treatment modalities of persistent pulmonary hypertension of the newborn and the potential use of phosphodiesterase 5 inhibitors such as sildenafil in a situation where the standard of practice with inhaled nitric oxide and extracorporeal membrane oxygenation is not available.

[Salmonella osteomyelitis in a child with sickle cell disease]

In an eight-months-old girl with sickle cell disease, osteomyelitis due to Salmonella arizona was diagnosed. Osteomyelitis caused by Salmonella species is rare in children. However, in patients with sickle cell disease it is the responsible pathogen in more than 50% of cases. The differentiation between, the much more common, bone crisis and osteomyelitis in sickle cell patients is often difficult. Ultrasound and bone marrow scans may be helpful. It is not known why Salmonella causes osteomyelitis in patients with sickle cell disease. What is clear, however, is that osteomyelitis usually occurs shortly after a preceding bone crisis. Empiric antibiotic treatment of osteomyelitis in patients with sickle cell disease should include coverage for Salmonella species. The patient described was initially treated with cefuroxime and gentamicin, but once the culture result was known this was switched to amoxicillin. As new infection foci later occurred in the bone the treatment was switched to ceftriaxone i.v. which was later substituted by ciprofloxacin orally. With this all of the skeletal abnormalities were fully corrected.

Effect of cytokines on anticryptococcal activity of human microglial cells

The effect of selected cytokines on the antifungal activity of human microglia was studied with encapsulated and acapsular strains of Cryptococcus neoformans. None of the cytokines tested increased the fungistatic activity of microglia, suggesting that killing of cryptococci within the central nervous system is dependent on other host defense mechanisms.